Cornel N. Stanciu

Bright Light Therapy as Augmentation of Pharmacotherapy for Treatment of Depression: A Systematic Review and Meta-Analysis

Background Bright light therapy has demonstrated efficacy and is an accepted treatment for seasonal depression. It has been suggested that bright light therapy may have efficacy in nonseasonal depressions. Also, there is evidence that bright light therapy may improve responsiveness to antidepressant pharmacotherapy. Data Sources We searched PubMed/MEDLINE, PsycINFO, PsycARTICLES, CINAHL, EMBASE, Scopus, and Academic OneFile for English-language literature published between January 1998 and April 2016, using the keywords bright light therapy AND major depression, bright light therapy AND depress*, bright light therapy AND bipolar depression, bright light therapy AND affective disorders, circadian rhythm AND major depression, circadian rhythm AND depress*, and circadian rhythm AND affective disorder. Study Selection and Data Extraction Studies that reported randomized trials comparing antidepressant pharmacotherapy with bright light therapy ≥ 5,000 lux for ≥ 30 minutes to antidepressant pharmacotherapy without bright light therapy for the treatment of nonseasonal depression were included. Studies of seasonal depression were excluded. Following review of the initial 112 returns, 2 of the authors independently judged each trial, applying the inclusionary and exclusionary criteria. Ten studies were selected as meeting these criteria. Subjects in these studies were pooled using standard techniques of meta-analysis. Results Ten studies involving 458 patients showed improvement using bright light therapy augmentation versus antidepressant pharmacotherapy alone. The effect size was similar to that of other accepted augmentation strategies, roughly 0.5. Conclusions Analysis of pooled data from randomized trials provides evidence for the efficacy of use of bright light therapy ≥ 5,000 lux for periods ≥ 30 minutes when used as augmentation to standard antidepressant pharmacotherapy in the treatment of major depressive disorder and bipolar depression without a seasonal pattern.

Use of Buprenorphine in treatment of refractory depression—A review of current literature

OBJECTIVE Current treatment strategies for depressive disorders have limited efficacy, leaving many patients unimproved or with significant residual symptoms. The development of additional treatments represent a significant unmet need for providers. Several lines of evidence suggest that the opioid system may be involved in regulation of mood and incentives salience. Intervention based on modifying central opioid receptors may represent a novel approach to treatment of depressive disorders among those unresponsive to accepted treatments. DATA SOURCES We searched the English language literature using keywords: Buprenorphine AND Major Depression; Buprenorphine AND Bipolar Depression; Buprenorphine AND Affective Disorders. RESULTS Use of low dose buprenorphine as augmentation of pharmacotherapy for depression has shown promise in several reported studies. Effect size of available randomized controlled studies is comparable if not greater than most accepted augmentation strategies. CONCLUSION Review of available literature on the use of buprenorphine in individuals with treatment resistant depression demonstrated efficacy in the treatment of depressive disorders. Further prospective randomized controlled trials should be undertaken to evaluate the efficacy of buprenorphine as an adjunct for depression refractory to current pharmacotherapies.

The Behavioral Profile of Methylenedioxypyrovalerone (MDPV) and α– pyrrolidinopentiophenone (PVP) - A Systematic Review

The article entitled, “The Behavioral Profile of Methylenedioxypyrovalerone (MDPV) and α– pyrrolidinopentiophenone (PVP) - A Systematic Review”, submitted in Current Drug Abuse Reviews (CDAR) by Dr. Cornel N Stanciu has been withdrawn from the journal in accordance with BSP Editorial Policies.

Loperamide, the “Poor Man’s Methadone”: Brief Review

ABSTRACT Loperamide is widely available as an inexpensive, over-the-counter remedy commonly used for management of diarrhea. Although an opioid, at therapeutic doses it acts primarily on the gastrointestinal tissues; however, larger than recommended amounts facilitate central nervous system (CNS) penetration. Such high doses of loperamide have recently gained popularity among users of opioids to manage withdrawal symptomatology and, less frequently, to achieve psychoactive effects. Chronic loperamide use can result in development of tolerance and, upon abrupt cessation of use, withdrawal. With increasing prevalence of use, side-effects are noted, one particularly being life-threatening cardiac arrhythmias. Users are often not forthcoming and routine drug screens do not detect loperamide, so providers need to be alert to such practices in order to recognize intoxication, be able to screen for use, and facilitate entry into treatment.

Underutilization of Pharmacotherapy for Treatment of Alcohol Use Disorders Part II-Results from a Survey of Practices among North Carolina Mental Health Providers and Brief Review of Efficacy of Available Pharmacotherapies

Introduction: Alcohol is the third leading cause of preventable death worldwide. There is substantial risk for development of alcohol use disorder among those with psychiatric disorders, complicating their care. Despite extensive evidence in support from controlled trials and from expert opinion, medication-assisted treatment has had low levels of penetration in practice. Only 3% of sufferers receive FDA-approved treatment. The goal of this survey is to explore potential causes of underutilization of evidence-based pharmacotherapeutical agents in the treatment of alcohol use. Secondary, we analyze differences in practice patterns between different academic institutions, facilities specializing in chemical dependence treatment, and general community practitioners. We are aware of no prior study that has attempted to evaluate these factors. Methods: An online questionnaire was designed in Qualtrics and distributed through the use of an anonymous link. Target participants were members of the Psychiatry departments of four academic institutions in NC, community mental health providers, prescribers from chemical dependence treatment facilities, and Veteran Affairs psychiatrists. A total of 170 participated, an 85% response rate. Data was analyzed using Qualtrics software as well as by a statistician. Results: A significant portion of psychiatric patients have comorbid alcohol use, and despite patient interest, medications are rarely utilized in both academic as well as chemical dependence facilities-20% of respondents never prescribed any. Reasons mainly include lack of provider knowledge of available medications (r=-0.277, n=136, p=0.001), prescribing guidelines (r=-0.265, n=136, p=0.002) and dosing (r=-0.245, n=136, p=0.004). Provider’s attitude towards substance use treatment also affects prescribing (r=-0.21, n=136, p=0.014). Those who do prescribe seem to favor off-label medications and avoid Naltrexone IM formulation. Providers acknowledge that the majority of those with alcohol use disorders have medical conditions caused or affected by the ongoing use. Instituting medications leads to positive experiences: patients maintain sobriety longer, have less legal problems and are better able to engage in their care. Conclusion: In the treatment of alcohol use, guidelines recommend FDA approved medications in conjunction with bio psychosocial interventions. Global assessment indicates prescribers mainly avoid pharmacotherapy due to lack of comfort and knowledge. There may also be financial barriers in a current alcohol treatment system that is traditionally non-medically oriented. Although it is recommended to start with FDA approved medications, off-label use is high. Despite positive implications noted when medications are instituted, providers’ ambivalence continues. As part of our daily practices, general psychiatrists should gain confidence in using evidence-based, FDA approved, medications in treatment of alcohol use disorders.

Psychogenic polydipsia, hyponatremia and osmotic myelinolysis

Objective Description of a case of osmotic myelinolysis associated with hyponatremia produced as a consequence of compulsive water drinking. Method Case report and review of relevant literature. Results Compulsive water drinking or psychogenic polydipsia is a common cause of hyponatremia among individuals with chronic mental illness. Central pontine myelinolysis and extrapontine myelinolysis are serious neurological complications resulting from rapid correction of serum sodium and associated changes in serum osmolality. A case of extrapontine myelinolysis confirmed by characteristic MRI findings following an episode of extreme hyponatremia caused by psychogenic polydipsia is described involving a patient with an adult lifelong history of chronic mental illness diagnosed as schizoaffective disorder. With supportive care the related cognitive deficits and balance difficulties resolved completely. Conclusions Clinicians should be aware of the potential for hyponatremia resulting from compulsive water drinking to cause myelinolysis with delayed development of cognitive and gait symptoms that responds to supportive care if identified early.

Does "Hotboxing?" Get You High and Can You Test Positive? - A Brief Review of Second-Hand Cannabis Exposure, Intoxication and Urine Drug Screens

Cannabis use is on the rise with higher and higher potencies of marijuana being cultivated. Current legislatures make it easier, and legal, for users to use, especially around nonusers. When such second-hand smoke occurs in poorly ventilated confinements, nonusers may inhale some of the smoke, resulting in absorption of cannabinoids. Some degree of intoxication may occur but most importantly, detectable levels of the drug in blood and urine. Often screening is used by employers, law enforcement agencies, physicians and substance abuse providers. Clinicians hence need to be mindful of such factors when patients deny use despite positive tests. Here we review available evidence, with emphasis on current data based on today’s trends. Clinical background: “I have not smoked marijuana since before I was drafted” 23 year-old NFL player Josh Gordon stated as his explanation for testing positive above the 15 ng/mL THC threshold the NFL considers a failed test. In his appeal he stated he was around individuals using marijuana. His “A” sample tested at 16 ng/mL and his “B” sample tested at 13.63 ng/mL. The two should be consistent since it comes from the same specimen. His legal team was able to dispute the results and reduce his sentence to 8 months as he was the “victim of breathing second hand smoke” (ESPN, 2014).

Underutilization of Screening Tools for Alcohol Use Disorders Part I: Results from Survey of Practices among North Carolina Mental Health Providers and Brief Review of Available Instruments

Background: Alcohol is the third leading cause of preventable death worldwide. With growing co-occurrence in those with psychiatric disorders, identification of these disorders is of increasing relevance. Various screening tools have evolved for uses from detecting dependence to identifying hazardous patterns of use. Use of these tools has allowed early detection of those at risk facilitating interventions often before addictive use becomes established. Objectives: Here we report findings from a survey of mental health providers examining the use of screening instruments for alcohol use and their correlation to prescriptions for high-risk use and alcohol use disorders. We also review the available screening tools. Methods: An anonymous online questionnaire was distributed to providers in various settings (academic, community and chemical dependence and veterans affairs). A total of 170 participated, a response rate of 85%. Data was analysed using Qualtrics software as well as a statistician. Results: Screening is frequently avoided. Half of psychiatric providers have never used a screening tool. Community providers (Mdm=0%) use such tools much less than academic (Mdn=25%, U=852.5, p<0.001) and chemical dependence providers (Mdn=25%, U=90.5, p=0.001). Pharmacotherapy seems to be implemented more often by those that employ screening tools (Mdm=39.2%) compared to those that do not (Mdm=23.5%), U=1284.5, p<0.001. Conclusion: AUDs are highly prevalent and often go undiagnosed and subsequently untreated. Despite guidelines recommending use of screening tools, our survey indicates few providers have adopted them. When used, however, there seems to be a greater implementation of pharmacotherapy to address problem-drinking leading to better outcomes. All primary care and mental health professionals should consider use of screens for comorbid alcohol use.

“Meth Mouth”: An Interdisciplinary Review of a Dental and Psychiatric Condition

Objective: Chronic methamphetamine (MA) users experience many dental problems, a condition characterized as “meth mouth.” These devastating effects on dentition is the main reason why many seek professional help. Here, we discuss the effects of MA on oral health and advocate for improved collaboration between dentists and mental health providers. We also introduce a dental evaluation tool with the goal of improving the quality of care for this often-marginalized patient population. Methods: A Medline literature search (1985–2016) was conducted with keywords “meth mouth,” “methamphetamine AND oral health”; “methamphetamine AND dental”; “methamphetamine AND dentist.” Results were supplemented by references gleaned from recent reviews, credible online sources, and citations of search returns. Results: MA predisposes users to tooth decay. They are also more likely to have missing dentition with a linear relationship correlating the number of years of use. A constellation of dental symptoms resulting from chronic MA use has been described in literature: gingival inflammation, excessive tooth wear, decreased salivary output, and severe dental caries. With continued use, mucosal lesions may appear on the lips and the gingival tissue may recede. MA can trigger bruxism, resulting in severe wear patterns and even cracked teeth. Conclusions: Users of MA have many unmet medical and mental health needs. An interdisciplinary approach between dentists and mental health providers can improve outcomes. The dental evaluation tool described here can improve the bidirectional collaboration between mental health and dentistry. Dental professionals are in a unique position to identify users and can facilitate referral to substance abuse treatment. Likewise, mental health providers can identify, assess severity, and prompt users for medical and dental attention.